Estimating the Impact of Raising Prices and Eliminating Discounts on Cigarette Smoking Prevalence in the United States

Exposure to and Appeal of Tobacco Ads and Displays in China: A Qualitative Exploration of Chinese Youth Perceptions

INTRODUCTION

Adolescents are uniquely vulnerable to nicotine addiction, and smoking is common among male adolescents in China. Although China implemented a ban on cigarette and e-cigarette advertising in public places, Chinese youth remain exposed to this marketing, which may contribute to future use.

AIMS AND METHODS

From December 2021 to January 2022, we conducted 20 online focus group discussions with 119 adolescents in 10 Chinese cities to explore sources of tobacco marketing exposure, defined as exposure to cigarette and e-cigarette ads and product displays, and what features made marketing attractive.

RESULTS

All groups discussed exposure to tobacco ads/displays in public places, including locations near their home or school. Nearly all groups discussed that exposure to online tobacco ads was common, particularly exposure to e-cigarette commercial ads and posts made by classmates or friends selling e-cigarettes. Most groups identified how eye-catching colors, imagery, product packaging, and price promotions featured in e-cigarette ads/displays attracted their attention.

CONCLUSIONS

Results suggest Chinese adolescents are exposed to cigarette and e-cigarette ads and displays, many of which are placed in youth-friendly locations and contain youth-appealing features.

IMPLICATIONS

Only a handful of studies have examined the influence of cigarette and e-cigarette advertising on youth in the context of China. Prior research has established the relationship between youth exposure to tobacco marketing and increased susceptibility to future use. Our findings emphasize the importance of effectively enforcing and expanding restrictions on cigarette and e-cigarette marketing in order to protect youth from exposure and future smoking/vaping initiation.

Modeling the future of tobacco control: Using SimSmoke to explore the feasibility of the tobacco endgame in Korea

INTRODUCTION

We used a simulation model to assess the feasibility of reaching the tobacco endgame target (reducing the smoking prevalence to below 5% by 2050) and explored potential implementation strategies.

METHODS

The impact of strengthened tobacco-control policies on smoking prevalence was analyzed using Korea SimSmoke, a discrete-time Markov process. We considered the effects of various scenarios from 2023 and predictions were conducted until 2050. To confirm the stability of the results, deterministic and probabilistic sensitivity analyses were carried out by increasing and decreasing parameter estimates.

RESULTS

The implementation of tobacco-control policies in accordance with the WHO MPOWER (Μonitor tobacco use and prevention policies; Protect people from tobacco smoke; Offer help to quit tobacco smoking; Warn of the dangers of tobacco; Enforce bans on tobacco advertising, promotion, and sponsorship; Raise taxes on tobacco) measures were insufficient to achieve the tobacco endgame objective of 5% by 2050. The overall predicted smoking prevalence in 2050 is 4.7% if all policies are fully implemented in accordance with the FCTC guidelines together with a complete ban on the sale of cigarettes to people born after 2003 and annual 10% increases in price. Sensitivity analyses using the varying policy effect assumptions demonstrated the robustness of the simulation results.

CONCLUSIONS

For a substantive reduction in smoking prevalence, it is essential to strongly implement the MPOWER strategy. Beyond this foundational step, the eradication of smoking requires a paradigm shift in the perception of conventional tobacco-control policies, including a tobacco-free generation strategy and radical increases in the price of tobacco products.

Follow the money: a closer look at US tobacco industry marketing expenditures

INTRODUCTION

While much of the concern with tobacco industry marketing has focused on direct media advertising, a less explored form of marketing strategy is to discount prices. Price discounting is important because it keeps the purchase price low and can undermine the impact of tax increases.

METHODS

We examine annual US marketing expenditures from 1975 to 2019 by the largest cigarette and smokeless tobacco companies as reported to the Federal Trade Commission. We consider three categories: direct advertising, promotional allowances and price discounting. In addition to considering trends in these expenditures, we examine how price discounting expenditures relate to changes in product prices and excise taxes.

RESULTS

US direct advertising expenditures for cigarettes fell from 80% of total industry marketing expenditures in 1975 to less than 3% in 2019, while falling from 39% in 1985 to 6% in 2019 for smokeless tobacco. Price discounting expenditures for cigarettes became prominent after the Master Settlement Agreement and related tax increases in 2002. By 2019, 87% of cigarette marketing expenditures were for price discounts and 7% for promotional allowances. Smokeless marketing expenditures were similar: 72% for price promotions and 13% for promotional allowances. Price discounting increased with prices and taxes until reaching their currently high levels.

CONCLUSIONS

Between 1975 and 2019, direct advertising dramatically fell while price discounting and promotional expenditures increased. Local, state and federal policies are needed that apply non-tax mechanisms to increase tobacco prices and restrict industry contracts to offset industry marketing strategies. Further study is needed to better understand industry decisions about marketing expenditures.

Financial hardship during the COVID-19 pandemic and increased receipt of commercial tobacco discount coupons among US adults who use commercial tobacco

INTRODUCTION

Many individuals experienced financial hardship during the COVID-19 pandemic; yet commercial tobacco (CT) sales increased in the USA. We examined how experiencing financial hardships relates to increased CT discount coupon reception during the pandemic.

METHODS

A nationally representative sample of 1700 US adults who used CT during the 12 months prior to the survey were surveyed online during January to February 2021. Participants reported if they had received more discount coupons for various CT products during (compared with before) the pandemic. They also reported whether they experienced six different types of financial hardships since the pandemic, and the total number of hardships experienced was counted. Weighted multivariable logistic regressions were used to examine the associations between financial hardships and increased coupon reception, adjusting for demographics and CT product use.

RESULTS

During the first 10-11 months of the pandemic, 21.3% of US adults who used CT during the 12 months prior to the survey reported receiving more CT discount coupons. Experiencing financial hardship during the pandemic was associated with higher odds of receiving more coupons for all types of CT products: every additional count of financial hardship was associated with higher odds of increased reception of discount coupons for all CT products (adjusted odds ratios ranging from 1.13 to 1.23 across products).

CONCLUSIONS

Over one-fifth of US adults who used CT received more discount coupons during the pandemic. Those facing financial hardships had higher discount coupon reception, suggesting potential targeted marketing to financially vulnerable individuals by the tobacco industry.

"They're sleek, stylish and sexy:" selling e-cigarettes online

OBJECTIVE

We examined the product range, marketing strategies, access and marketing claims made by Australian and New Zealand (NZ) online e-cigarette retailers.

METHODS

Twenty Australian (n=10) and NZ (n=10) e-cigarette retail websites were identified via Google using a combination of keywords nominated by an expert panel and identified via a literature review: 'e-cigarette', 'e-cigs', 'vape', and 'vaping', combined with 'Australia', 'AU', 'New Zealand' and 'NZ' and then examined.

RESULTS

Products were extensive (disposable, pod-based, reusable, replacement parts), 95% (n=19) offered 'Starter Kits,' flavoured e-liquid (n=1,032), most containing nicotine (70%, n=14). Most retailers (85%, n=17) offered price discounts and free delivery. There were unsubstantiated health claims (80%, n=16), cessation claims (65%, n=13) and cost-benefit claims (50%, n=10) promoting e-cigarette use. Most (n=14) website age verification features simply required the purchaser to indicate they were aged 18 years.

CONCLUSIONS

Although e-cigarette regulations are different in Australia and NZ, the online product range, marketing strategies, access and marketing claims were similar and sold e-liquid containing nicotine. The health and cessation e-cigarette marketing claims were outlandish and unsubstantiated.

IMPLICATIONS FOR PUBLIC HEALTH

Most purchasing of e-cigarettes occurs online. Regulations and enforcement to limit access and stop unsubstantiated marketing claims must be a public health priority.

Addressing lower-priced cigarette products through three-pronged comprehensive regulation on excise taxes, minimum price policies and restrictions on price promotions

The prices that smokers pay out-of-pocket for their tobacco products ultimately influence their smoking behaviour. Although cigarette excise taxes are arguably the best and most used policy to increase cigarette prices, taxes are only one component of retail cigarette prices. The persistence of lower-priced products, disproportionately purchased by lower-income smokers, in jurisdictions with high excise taxes is an Achilles heel for tobacco tax policy. When governments raise excise taxes, the tobacco industry responds. The industry reduces tax pass-through to minimise the price increases for lower-priced brands and offers price discounts to retailers and coupons to consumers. In addition, smokers who do not quit after tax increases may downshift brands, purchase in bulk or substitute lower-priced tobacco product types. This may be particularly true for price-sensitive smokers, including those with lower incomes. We propose that raising excise taxes will be more effective in reducing the persistence of lower-priced products and income-based smoking disparities when taxes are designed to raise prices frequently and substantially for all products and are combined with (a) minimum price laws and (b) bans on coupons, discounts and other promotions. In combination, these three complementary policies restrict the tobacco industry's ability to undermine the impact of higher excise taxes upon consumer prices. Very few jurisdictions have implemented comprehensive three-pronged tobacco price regulation, but doing so would likely address many of the limitations that come with a sole focus on raising excise taxes.

Cognitive Behavioral Therapy and Acceptance and Commitment Therapy for the Discontinuation of Long-Term Benzodiazepine Use in Insomnia and Anxiety Disorders

Benzodiazepines have proven to be highly effective for treating insomnia and anxiety. Although considered safe when taken for a short period of time, a major risk–benefit dilemma arises in the context of long-term use, relating to addiction, withdrawal symptoms, and potential side effects. For these reasons, benzodiazepines are not recommended for treating chronic sleep disorders, anxiety disorders, nor for people over the age of 65, and withdrawal among long-term users is a public health issue. Indeed, only 5% of patients manage to discontinue using these drugs on their own. Even with the help of a general practitioner, this rate does not exceed 25 to 30% of patients, of which approximately 7% manage to remain drug-free in the long term. Cognitive Behavioral Therapies (CBT) offer a crucial solution to this problem, having been shown to increase abstinence success to 70–80%. This article examines traditional and novel CBT techniques in this regard, such as Acceptance and Commitment Therapy, which address both the underlying condition (insomnia/anxiety) and the substance-related disorder. The theoretical framework and evidence supporting the use of these approaches are reviewed. Finally, current research gaps are discussed, and key research perspectives are proposed.

Effects of a minimum floor Price law on cigarette use in Oakland, California: A static microsimulation model

Tobacco minimum floor price laws (MFPLs) are a non-tax price policy that set a price below which tobacco products cannot be sold, thereby raising prices. Despite their growing interest among policy makers, little is known about the effects of local MFPLs on smoking prevalence or smoking intensity. We aimed to project the impact of a local tobacco MFPL on cigarette smoking prevalence and cigarette smoking intensity in Oakland, California, including detailed analysis of several important subpopulations. We used data collected between April 2017 and December 2019 from the California Behavioral Risk Factor Surveillance System and the National Youth Tobacco Survey to construct a static microsimulation model representative of Oakland. We projected the impact of MFPLs ranging from $8.00 to $13.00 per pack. All analyses were conducted between 2019 and 2020. With the introduction of an MFPL and assuming 15% policy evasion, mean price paid per pack was projected to increase by $1.05 to $4.69, cigarette smoking prevalence was projected to drop by 0.3% to 0.8%, and smoking intensity was projected to drop by 0.7% to 2.0% among continuing smokers. Total number of cigarettes smoked per month was projected to drop by 246,000 to 734,000 cigarettes, a 3.0% to 9.0% reduction from the current level (8.2 million cigarettes). The greatest reductions in cigarette smoking prevalence were among those aged 12 to 24-years-old, of non-Hispanic black or other race/ethnicity, and living below the federal poverty level. An MFPL in Oakland may substantially reduce cigarette use and target several important subpopulations.

Tobacco manufacturer lobbying to undercut minimum price laws: an analysis of internal industry documents

BACKGROUND

Increasing the price of tobacco products has the potential to reduce tobacco consumption. As other forms of promotion have been increasingly restricted over time, tobacco manufacturers have relied more on trade discounts. Minimum price laws that prevented the use of manufacturer promotions were once common; however in most US jurisdictions these discounts are now legally protected.

METHODS

We collected tobacco industry documents, state legislation and court cases between 1987 and 2016 to review tobacco manufacturer strategies to change minimum price laws in the USA.

RESULTS

Beginning in 2000, tobacco manufacturers lobbied to amend minimum price legislation after state regulators indicated that manufacturer promotions were illegal under existing laws. Companies viewed changing these laws as critical to maintaining tobacco sales, and after the initiation of an industry lobbying campaign, at least 20 states changed the way they calculated tobacco prices.

CONCLUSIONS

Modifying existing minimum price laws so that manufacturer discounts are no longer protected, and implementing new minimum price policies with comparable scope, would likely increase prices and reduce tobacco use.

Effects of Cigarette Prices on Intention to Quit, Quit Attempts, and Successful Cessation Among African American Smokers

INTRODUCTION

This study examined the effects of cigarette price on intention to quit, quit attempts, and successful cessation among African American smokers in the United States and explored whether price effects differed by income level and menthol use status. Price effects were further compared to White counterparts.

METHODS

We used pooled cross-sectional data from 2006 to 2007 and 2010 to 2011 Tobacco Use Supplements to the Current Population Survey to analyze 4213 African American recent active smokers. Three dependent variables were examined: any quit attempts in the past 12 months, successful cessation for at least 3 months, and intention to quit in the next 6 months. For each dependent variable, separate multiple logistic regression models were estimated to determine the impact of cigarette prices.

RESULTS

There was no indication that price was associated with quit attempts or successful cessation, but price was positively associated with increased odds of intending to quit among African American smokers (p < .001). In contrast, prices were positively associated with intention to quit and quit attempts for White smokers. The association between price and intention to quit was significantly positive for African American low-income and menthol smokers but was not statistically significant for African American high-income and non-menthol smokers. There was no evidence of a price effect on quit attempts and successful cessation for each subgroup of African Americans.

CONCLUSIONS

Tobacco tax policy alone may not be enough to increase quit attempts or successful cessation among African Americans. Community-based cessation programs tailored toward African American smokers, especially low-income menthol smokers, are needed.

IMPLICATIONS

The results revealed that, among African American smokers, particularly among low-income and menthol smoking African American smokers, price appears to be positively associated with intention to quit; nevertheless, this deterrent effect does not appear to translate to actualized quit attempts or successful cessation. Increasing cigarette prices as a standalone policy may not be independently effective in increasing quit attempts and successful cessation within the African American community. Community-based cessation interventions tailored for African Americans are needed to help further translate desired cessation into actualized quit attempts.

Association between purchasing behaviors and cigar use: A longitudinal analysis of Waves 1-3 of the Population Assessment of Tobacco and Health (PATH) Study

Introduction

Over 120 US jurisdictions have implemented policies mandating minimum cigar pack quantities, yet little empirical research exists on the relationship between pack quantity and use. We examined whether cigar use was associated with purchasing cigars by the box/pack or as singles, purchase quantity, and price paid per cigar.

Methods

Data are from Waves 1–3 (2013–2016) of the Population Assessment of Tobacco and Health (PATH) Study, analyzed in 2019. The sample included adults who reported current use of any type of cigars (cigarillos [N = 3,051], traditional cigars [N = 2,586], and filtered cigars [N = 1,295], including with marijuana) at Wave 1. For each cigar type, a generalized estimating equation model was used to examine the population-averaged effects of purchasing behavior on cigar use.

Results

Cigar users of each type who purchased by the box or pack smoked more per day than users who purchased singles (cigarillos: β = 1.02, p<0.0001; traditional cigars: β = 1.40, p<0.0001; filtered cigars: β = 2.55, p<0.01). Cigar users who purchased larger quantities smoked more per day (cigarillos: β = 0.16, p<0.0001; traditional cigars: β = 0.04, p<0.0001; filtered cigars: β = 0.24, p<0.0001). Higher price per cigar was significantly associated with smoking fewer traditional cigars (β = -0.12, p<0.01) and filtered cigars (β = -0.86, p = 0.02), but not cigarillos (β = 0.08, p = 0.62).

Conclusions

Smaller pack quantities and higher price per cigar were associated with smoking fewer cigars per day. Given the authority of the Food and Drug Administration and local jurisdictions over cigar pack quantity, this study provides data pertinent to potential minimum and maximum package quantity regulations and policies.

Mind the Gap: Changes in Cigarette Prices After California's Tax Increase

Objective

To investigate whether California's 2017 cigarette tax increase was passed onto smokers equally.

Methods

Auditors recorded 4 cigarette prices in the same random sample of licensed tobacco retailers (N = 1049) before the tax increase (January-March 2017) and after (April-September 2018): Natural American Spirit (ultra-premium), Newport menthol (premium), and Pall Mall (value) all from the same manufacturer, and Marlboro (premium). Ordinary least squares regressions examined how the gap in prices (increase greater or less than $2.00 tax) varied by market segment and neighborhood demographics, controlling for store type and months since implementation. Paired t-tests assessed whether industry/retail revenue (price in excess of state and federal excise taxes) increased.

Results

Over-shifting (increase greater than tax) was evident for all 4 brands and was significantly greater for ultra-premium (Mean = $0.40, SD = 0.75) than premium (Mean = $0.25, SD = 0.78) and greater for premium than value brand (Mean = $0.16, SD = 0.67). However, under-shifting (increase less than tax) was evident for Newport in African-American neighborhoods and Pall Mall in Hispanic neighborhoods. After the tax increase, prices were significantly more likely to be discounted and significantly more stores advertised a discount on cigarettes.

Conclusion

California's tax increase was not passed onto consumers equally. Non-tax mechanisms to increase price could support intended effects of tobacco taxes.

The impact of a federal cigarette minimum pack price policy on cigarette use in the USA

BACKGROUND

Increasing cigarette prices reduce cigarette use. The US Food and Drug Administration has the authority to regulate the sale and promotion-and therefore the price-of tobacco products.

OBJECTIVE

To examine the potential effect of federal minimum price regulation on the sales of cigarettes in the USA.

METHOD

We used yearly state-level data from the Tax Burden on Tobacco and other sources to model per capita cigarette sales as a function of price. We used the fitted model to compare the status quo sales with counterfactual scenarios in which a federal minimum price was set. The minimum price scenarios ranged from $0 to $12.

RESULTS

The estimated price effect in our model was comparable with that found in the literature. Our counterfactual analyses suggested that the impact of a minimum price requirement could range from a minimal effect at the $4 level to a reduction of 5.7 billion packs sold per year and 10 million smokers at the $10 level.

CONCLUSION

A federal minimum price policy has the potential to greatly benefit tobacco control and public health by uniformly increasing the price of cigarettes and by eliminating many price-reducing strategies currently available to both sellers and consumers.

Behavioral change in response to a statewide tobacco tax increase and differences across socioeconomic status

BACKGROUND

Tobacco use is a leading behavioral risk factor for morbidity and mortality, and the tobacco epidemic disproportionately affects low-socioeconomic status (SES) populations. Taxation is effective for reducing cigarette use, and it is an effective population-based policy for reducing SES-related tobacco disparities. However, progress in implementing cigarette excise taxes has stalled across the United States, and there is a dearth of research on the full spectrum of behavioral shifts that result from taxes, particularly among low-SES populations. This project documents the impact of Minnesota's $1.75 cigarette tax increase implemented in 2013.

METHODS

Data come from the 2014 Minnesota Adult Tobacco Survey. Descriptive analyses and Latent Class Analysis (LCA) were used to provide a typology of the tax impact.

RESULTS

From the LCA, six classes were identified, and 42% of respondents were classified as reporting action-oriented behavioral change related to the tax-8% reported sustained smoking abstinence. We found differential behavior change across levels of SES. Low-SES and medium/high-SES individuals were equally likely to report complete tobacco cessation, but the prevalence of daily smokers who reported action-oriented behavior without sustained cessation was nearly double for low-SES individuals.

CONCLUSIONS

Smokers report a range of behavioral changes in response to cigarette taxes, with differences across SES. The majority of smokers, and particularly low-SES smokers, report behavioral steps toward quitting or achieving sustained tobacco cessation in response to cigarette taxes. Complementary population-based programs geared toward assisting individuals, especially low-SES individuals, to achieve continuous tobacco cessation could increase the reach and effectiveness of cigarette taxes.